Who you are:
You are an FY2 in the GP clinic.Who the patient is:
Laura Flick ,aged 10 days old, has been brought in by her mother.What you should do:
Talk to her and address her concerns.
Doctor: Hi I’m one of the junior doctors here.
Patient: Hello doctor.
D: Can I confirm your name please?
P: Doctor my name is Matilda.
D: Can I get your daughter’s full name and DATE OF BIRTH PLEASE?
(Confirm date of birth, rather than age, as it’s a more precise way of confirming ID.)
P: I am Serena’s mum, she is 10 days old.
D: Okay, is Serena here with us today?
P: No.
D: Okay that’s fine, how can I help you today?
P: Doctor, my baby has a rash on her thigh . (P1)
D: Could you please elaborate a bit more for me ? OPEN Qs
P: I was changing my baby’s nappy and I saw some spots/ rash on her thigh I was very curious to know how a 10 day old baby can have it, that’s why I came here to ask about it. Onset
D: I am sorry to hear that, I can see you are anxious about it. Can I ask a few more
questions about it so that I can understand it better? Reflect
P: Sure doctor
ODIPARA
D: Could you please tell me when it started? Duration
P: I don’t know doctor, but I saw it last night.
D: What is the shape of the rash?
Any change in the shape of the rash?
P: Doctor I have a picture of it.
D: What is the Size of the rash? Any change in the size?
P: Like a coin.
D: What is the Colour of the rash? Any change in the color?
P: Red in color.
D: Any discharge/bleeding from the rash?
P: No discharge.
D: Is it itchy or painful?
P: I’m not sure
D: Fever or flu-like symptoms?
P: No.
NAI very important
D: Who is with Serena now?
P: My husband is looking after her. He takes good care of her .
D: Was it a planned pregnancy?
P: Yes doctor.
Head to toe quickly remember paediatric structure
D: Does she cry after moving her neck ?
P: No.
D: Any problems with her wee? Any problems with her poo? How’s the general health of the baby? Is she feeding well?
BIRDDD
D: How was her birth?
P: NVD.
D: Was she delivered at full-term?
P: No doctor. She was delivered at 35 weeks.
D: Did she have a low birth weight?
P: Yes, she was low birth weight.
D: Was it multiple or twin pregnancies?
P: No.
D: Any congenital problems?
P: No.
D: Family history of any diseases?
P: No.
D: Do you have any IDEA of what it is?
P: No.
D: Thank you very much for the information regarding your baby Serena .
Examination:
I would like to have a look at the rash and would ideally examine Serena’s general health as-well (but she is not here).
Examiner may show you a picture of the rash
Management:
Diagnosis
From what you have told me and from what I have assessed I suspect your baby just has a birthmark (strawberry or hemangioma ).
D: Have you seen one before? (concern)
P: Oh is that it?! No I haven’t seen one before.
Birthmarks are blood vessels that form coloured marks (raised red lumps) on the skin that are present at birth or soon afterwards. Most are harmless and disappear without treatment, but some may need to be treated.
Senior:
I would like to inform my seniors to get an expert opinion as well. Do you have any
concerns so far?
P: Is it serious? (concern)
D: Fortunately it is not, however the size may increase in the first few months but they then usually disappear by the age of 6 to 7 years .
NB: It is common in girls, premature babies (born before 37 weeks), low birth weight babies, and multiple births, such as twins get bigger for the first 6 to 12 months, and then shrink and disappear by the age of 7. May need treatment if they affect vision, breathing, or feeding.
P: How are you going to treat her now? ( concern )
D: Usually these birthmarks don’t need any treatment unless they are affecting her vision, breathing, or feeding.
Investigations
CT and MRI : Only if more than one to exclude internal organs hemangiomas or near eyes.
Lifestyle advice
Most of the time, haemangiomas just need looking after carefully.
− Haemangiomas can bleed if they’re scratched, so it’s important to keep your child’s nails short and buffed smooth to protect the surface of the lump.
− If the haemangioma starts bleeding, apply pressure with a clean piece of cloth or tissue for at least five minutes. If blood soaks through the material, put another one on top and keep up the pressure. Don’t take it off to have a look, as this could start the bleeding again.
− If the bleeding continues, even after pressing down on the haemangioma for five minutes, we recommend people go to your nearest NHS Walk-In Centre or Accident and Emergency department.
− The surface of the haemangioma is delicate and can get dry, so avoid using bubble bath,rinse any soap or shampoo off carefully and pat the area gently afterwards.
− A thin layer of Vaseline® put gently over the top twice a day can stop it drying
out.
− Baby wipes can be irritating, so a better alternative is to use damp cotton wool.
− Sun protection, with high factor sun cream on all areas of exposed skin, use a hat to protect the child’s face and/or an umbrella over the buggy or pushchair.
Treatment:
Larger, visceral, or life-threatening lesions may be removed.
Options include:
- Medicines – to reduce blood flow to the birthmark, which can slow down its
growth and make it lighter in color. - Laser therapy – where heat and light are used to make the birthmark smaller and
lighter (it works best if started between 6 months and 1 year of age). - Surgery – to remove the birthmark (but it can leave scars).
- Embolisation therapy
A birthmark can be removed on the NHS if it’s affecting a person’s health. If you want a birthmark removed for cosmetic reasons, you’ll have to pay to have it done privately.
Specialist:
Refer to skin specialist if suspicious or affecting life or getting worse or started showing red flags.
Safety net:
Come back to the GP if you’re worried about a birthmark or you start noticing any of
these:
RED FLAGS
− Your child has 6 or more cafe-au-lait spots.
− You or your child has a large congenital mole.
− If close to the eye, nose, or mouth.
− If getting bigger, darker, or lumpier.
− If sore or painful.
Follow up:
The Birthmark Support Group has information about other type of birthmarks and getting help and support.
4 POINTS RECAP:
- NEWBORN WITH SKIN LESION RED LUMPY
- NOT SERIOUS, DISAPPEAR LATER IN LIFE
- TREAT ONLY IF AFFECTING LIFE
- ADVICE AND SAFETY NET